A case report on letrozole-related maculopathy.

Letrozole is an oral aromatase inhibitor used in the treatment of hormone receptor-positive breast cancers in postmenopausal women. It acts by inhibiting the conversion of androgens to estrogen thereby lowering the estrogen synthesis in the body. We report a case of bilateral cystoid macular edema (CME) in a postmenopausal woman on letrozole for breast cancer. A 62-year-old female presented with painless gradually progressive bilateral diminution of vision for the past 6 months. Her previous ocular history is unremarkable. Her medical history is known for carcinoma of the breast for which she underwent chemotherapy followed by mastectomy, adjuvant hormonal therapy, and radiotherapy. The patient had been on letrozole for the past 4½ years. At presentation, the best corrected visual acuity in the right eye was 0.4 and 0.5 in the left eye. Fundus examination revealed significant bilateral CME. Optical coherence tomography and fundus fluorescein angiography confirmed the diagnosis. After discussing the possibility of letrozole-related maculopathy with the treating oncologist, letrozole was discontinued and the patient was reassessed. Reduction of macular edema and mild visual improvement was observed when letrozole was subsequently stopped. Although ocular side effects are rare with letrozole, a comprehensive ophthalmic evaluation is recommended for patients who present with visual disturbances for prompt intervention.

Acute postoperative infectious endophthalmitis caused by Gram-negative organisms.

Endophthalmitis is a rare but potentially sight-threatening ophthalmic condition characterized by marked inflammation of intraocular tissues and fluids. Bacteria is the most common cause of postoperative acute infectious endophthalmitis of which Gram-positive (GP) bacteria is the predominant isolate which constituted 47% of all positive vitreous cultures in endophthalmitis vitrectomy study. On the other hand, Gram-negative bacteria constituted 11.5% with poor visual outcomes compared to GP cases due to the fulminant and destructive nature of such pathogens despite prompt and appropriate treatment initiation. In this report, we would like to share the three cases of acute postoperative infectious endophthalmitis caused by Gram-negative organisms and highlight the challenges that might be faced when dealing with such presentations.

Bilateral serous retinal detachment: An initial presentation of mixed phenotype acute leukemia in an adult.

A 60-year-old female presented with acute onset painless loss of vision in both eyes. Clinical examination and ocular investigations revealed bilateral serous retinal detachments (SRDs) over the macula. There was no obvious intraocular or extraocular cause to the presentation. A blood count showed leukocytosis with the presence of blast cells on the peripheral smear. Further workup confirmed the diagnosis of Philadelphia chromosome-positive mixed phenotype acute leukemia with central nervous system disease stage three. Anatomic improvement in the SRD followed intensive intravenous and intrathecal chemotherapy. Limited functional improvement was attributed to the development of pigment epitheliopathy manifesting as leopard spot chorioretinopathy. This permanent disturbance could be attributed to leukemic infiltration and ischemia to the choroid.

Complications associated with the use of two types of silicone oil in vitreoretinal surgeries: A single tertiary center experience in Oman.

OBJECTIVES: The objective of this study is to describe complications associated with the use of two types of silicone oil (SO) (1000 centistokes [cs] and 5000 cs) in vitreoretinal surgery in Oman. MATERIALS AND METHODS: This is a retrospective descriptive study on all patients who underwent vitreoretinal surgeries in which SO injection or removal was done. The study was conducted at Sultan Qaboos University Hospital between January 1, 2010, and December 31, 2017. Demographic data, lens status of the eye at the time of SO injection, type of SO used (1000 cs or 5000 cs), and complications associated with SO were collected. RESULTS: A total of 107 eyes of 103 patients were included in the study. SO 1000 cs was used in 66 eyes and SO 5000 cs was used in 41 eyes. A total of 29 eyes (27%) developed SO-related complications, which included SO emulsification in 14 eyes (13.1%), raised intraocular pressure (IOP) >21 mmHg in 19 eyes (17.8%), and band keratopathy in 4 eyes (3.7%). SO emulsification was seen in eight eyes (12.1%) in whom SO 1000 cs was used and in five eyes (12.2%) in whom SO 5000 cs (P = 1.000). CONCLUSION: SO was found to be a relatively safe adjunct in vitreoretinal surgery. SO-related complications such as SO emulsification, raised IOP, and band keratopathy were observed in less than one-third of study eyes. No difference was noted in emulsification rate between SO 1000 cs and SO 5000 cs. Further studies with larger sample size and longer follow-up period are warranted.

Postprocedural Endophthalmitis or Postprocedural Intraocular Inflammation: A Diagnostic Conundrum.

We experienced an atypical endophthalmitis occurring post consecutively performed in-office procedures; an intravitreal injection (IVI) of ranibizumab followed by an anterior chamber (AC) paracentesis performed twice in an eye with neovascular glaucoma (NVG). A 52-year-old diabetic male who was asymptomatic developed signs of endophthalmitis and decreased vision without pain in his left eye a few days post-IVI and AC paracentesis. The condition worsened after an initial vitreous tap and injection of antibiotics. Cultures of vitreous and aqueous samples were negative. Complete resolution occurred after a pars plana vitrectomy with IVI of antibiotics and steroid with removal of a dense "yellowish-brown" fibrinous plaque. The absence of pain, presence of a peculiar colored fibrin, mild-to-moderate vitritis without retinitis, negative cultures, and complete recovery despite the fulminant presentation; favor a diagnosis of inflammation over infection. We hypothesize that a micro-leak from a 26-gauge AC tap tract might have served as an entry port for 5% povidone-iodine from the ocular surface thus inciting inflammation. However, an exuberant inflammatory response that can be typically seen in NVG eyes after intraocular procedures cannot be excluded. Various causes of inflammation post-procedures, both toxic and nontoxic should be considered in atypical culture-negative fulminant endophthalmitis cases with good outcome posttreatment. Any minor ocular procedure may carry a risk of such complication. Patient counseling and care must be exercised in performing these procedures.

Central Retinal Vein Occlusion in a Young Healthy COVID-19 Patient: A Case Report and Literature Review.

Coronavirus disease (COVID-19) has been declared by the World Health Organization as a pandemic on March 11, 2020. COVID-19 predispose patients to multisystem thromboembolic events, including pulmonary emboli and deep vein thrombosis. We report a 33-year-old previously healthy man, with previous history of COVID-19 infection presented with left eye central retinal vein occlusion (CRVO) with secondary macular edema. All possible risk factors for thromboembolic events were excluded. After a single dose of intravitreal injection of aflibercept (2 mg in 0.05 ml), gradual improvement in the clinical manifestation of CRVO with complete resolution of macular edema in the left eye was observed. To the best of our knowledge, this is the first report of CRVO post-COVID-19 in Oman.

Unusual case of endophthalmitis: Case report and literature review.

Endophthalmitis is an inflammation of both the anterior and posterior chamber. It is diagnosed clinically and involvement of retina and choroid has been documented. (1) Endophthalmitis is classified into infectious and no-infectious categories. Furthermore, the infectious categoery is classified into endogenous and exogenous (Postoperative, Posttraumatic, Bleb associated) which can be caused by either bacterial or fungal infection. Blurry of vision and pain are main symptoms and coagulase negative organisms (gram positive) are main causative of exogenous endophthalmitis. (2) We report a rare case of delayed-onset postoperative endophthalmitis secondary to a rare causative pathogen.

Endophthalmitis in Oman: A descriptive retrospective multi-center study.

PURPOSE: The aim of this study is to report the anatomical and functional outcome, microbiology profile and treatment used for endophthalmitis in Oman. DESIGN: The study design involves retrospective descriptive multicenter study. METHODS: Demographic and clinical data of patients diagnosed with endophthalmitis over a period of 9 years were collected in three tertiary hospitals in Oman. RESULTS: A total of 50 endophthalmitis cases were included in the study. Exogenous endophthalmitis was diagnosed in 48 cases, whereas 2 cases were endogenous endophthalmitis. Culture-positive cases constituted 16 cases (32%) out of these, 12 cases were Gram-positive, 3 cases were Gram-negative and one case had a positive fungal culture. Immediate first-line treatment was vitreous tap and inject in 33 eyes and vitrectomy in 13 eyes. In 45 eyes in which the visual acuity (VA) was recorded; VA after treatment improved in 22 eyes (49%), remained the same in 16 eyes (36%) and worsened in 7 eyes (16%). CONCLUSION: Although endophthalmitis is rare, it is a devastating ocular emergency. Early diagnosis and prompt intervention are crucial in management. Awareness among the patients undergoing intraocular surgeries about this rare condition is very crucial. Moreover, frontline health-care providers must be aware and critical if they encounter patients with suspicion of endophthalmitis as early recognition, prompt referral, and timely treatment are the key for better visual prognosis. Finally, establishing a National Endophthalmitis Registry is recommended as it will help analyze the incidence, treatment instituted and the outcome of this condition across Oman.

Determinants of Provision of Bystander Cardiopulmonary Resuscitation among the General Public in Oman.

OBJECTIVES: The aim of this study was to determine the factors that affect the provision of bystander cardiopulmonary resuscitation (CPR) among the general public in Oman. METHODS: This was a descriptive cross-sectional study performed over a two-month period from November to December 2018 using a questionnaire among the general public with no medical background. RESULTS: A total of 1,080 individuals were included in the study. The median age of the participants was 27 (20-39) years old with 624 (57.8%) male participants. More than half of the participants (52.9%) were willing to perform CPR on a stranger. Lack of knowledge of CPR and a fear that they might cause more harm were the main reasons precluding people from performing CPR. Age, educational status and having attended a CPR course were predictors of willingness to perform CPR. CONCLUSION: There is a positive attitude towards bystander CPR in Oman among the general public. More education and training opportunities should be made available in workplaces and educational institutions.

Normal electro-oculography in a young Omani male with genetically confirmed best disease complicated by choroidal neovascularization.

Best vitelliform macular dystrophy (VMD) is an autosomal dominant macular dystrophy caused by heterozygous mutations in the bestrophin1 gene. Patients with this condition typically have an abnormal electrooculogram. We report a case of a 16-year-old male who presented with gradual progressive vision loss in the right eye. Ophthalmic assessment included funduscopy, optical coherence tomography (OCT), fluorescein angiography, electro-oculography, electroretinography, and genetic testing. Visual acuity was 20/500 and 20/20 in the right and left eyes, respectively. Ophthalmoscopy revealed round yellow lesions in both foveae similar to what is typically seen in Best disease. A subretinal hemorrhage surrounding the right foveal lesion was also noted. OCT demonstrated an elevated neurosensory retina with a subretinal lesion in the right macula. Fluorescein angiography of the right eye confirmed the presence of choroidal neovascularization. Genetic analysis of VMD2/BEST1 sequences confirmed the diagnosis of Best disease. However, contrary to what was expected, the patient's electro-oculography was normal. The findings of this case support a small number of previous reports demonstrating cases of Best disease with normal electro-oculography. While an abnormal electro-oculography along with the typical features of Best disease confirms the diagnosis, a normal result may not exclude the diagnosis. Genetic testing is probably the most important test for establishing the diagnosis of Best disease.

Corneal epithelial defect after pars plana vitrectomy.

AIM: This study aims to study the incidence of corneal epithelial defect (CED) after pars plana vitrectomy (PPV) and associated patient-related risk factors. The incidence of other immediate postoperative complications was also in the scope of this study. DESIGN: Retrospective descriptive case series study. METHODS: Review of electronic medical records of all patients who underwent PPV alone or combined with cataract surgery and/or scleral buckle in a tertiary hospital by one retinal surgeon. All demographic data, surgery notes, and immediate postoperative findings were obtained for all patients. RESULTS: The cohort of the included cases was composed of a total of 168 procedures that were performed in 121 eyes of 106 patients over 5 years. CEDs occurred in 19 eyes (15.7%) of 19 patients (17.9%). Males were affected more than females (90% vs. 10%). Patients with postoperative CED were found to have longer duration of surgery when compared to patients without postoperative CED (P = 0.0038). All cases of CED had a complete resolution of the defects after supportive therapy. Immediate intraocular hypertension (IOH) was found in 30 eyes (24.8%). IOH was controlled in all cases with medical therapy only. Post-PPV immediate complications, other than CED and IOH, occurred in 10.7% of the eyes. These included vitreous hemorrhage, choroidal detachment, corneal edema, anterior chamber fibrin, and hyphema. CONCLUSION: Development of CED is not uncommon after PPV. This complication is more common in males and may be related to prolonged duration of surgery. It also develops more in older patients. CED after PPV can be managed with conservative treatment with good outcome.

Experience of intravitreal triamcinolone acetonide for treatment of diabetic macular edema among Omani population.

PURPOSE: The purpose of this study was to evaluate the outcome of intravitreal (IVT) triamcinolone in diabetic macular edema (DME). MATERIALS AND METHODS: A retrospective study of 42 eyes diagnosed clinically and supported with optical coherence tomography (OCT), with DME of more than 300 µm in thickness. All eyes were injected with a single IVT injection of preservative free triamcinolone acetonide (TA) with dose of 4 mg. Patients were subjected to visual acuity (VA) and OCT on each follow-up visit which was continued for 6 months. The total number of IVT injections given was 48. Six eyes had a repeat injection. None of the eyes had any other IVT injection within 6 weeks of TA. Twenty-one eyes were pseudophakic. RESULTS: Mean age of the patients was 58.8 years. The mean central subfield thickness (CST) at baseline was 504.6 µm. At 6 weeks, the mean CST dropped by 183.6 µm (P < 0.00001). At 6-month follow-up, the mean CST had increased by 74.6 µm from 6 weeks level; however, the 6-month mean CST was 109 µ less than mean baseline thickness (P < 0.0005). The mean baseline VA was 0.80 LogMAR units. At 6 weeks, the mean VA dropped by 0.01 LogMAR. At 6 months, VA improved by 0.02 LogMAR units from baseline. Overall, VA improved in 47% eyes, dropped from baseline in 35% eyes, and remained unchanged in 18% eyes. CONCLUSION: Triamcinolone acetonide is a safe, effective, and promising therapy in DME.

Experience of intravitreal injections in a tertiary Hospital in Oman.

AIM: To find out statistical data regarding intravitreal injections in an outpatient department setup at a tertiary center in Oman. DESIGN: Retrospective chart review. METHODS: Data collection of patients who underwent intravitreal injections from November 2009 to May 2013 at Sultan Qaboos University Hospital. RESULTS: Throughout a period of 42 months, a total of 711 intravitreal injections were performed. That included 214 patients (275 eyes). Around one-third of the eyes received two injections or more. The injected agents were bevacizumab (59.8%), ranibizumab (32.3%), triamcinolone (7.5%), and very few patients with endophthalmitis received intravitreal antibiotics and antifungal agents. The three most common indications for the injection therapy were diabetic macular edema (50.9%), choroidal neovascularization (24.3%), and retinal vein occlusive diseases (11.5%). Serious adverse events were rare, and they occurred as ocular (0.9% per patient) and systemic (3.3% per patient). There were 42 eyes received intravitreal triamcinolone, and 24% of them developed intraocular hypertension that required only medical treatment. CONCLUSION: Different intravitreal agents are currently used to treat many ocular diseases. Currently, therapy with intravitreal agents is very popular, and it carries a promising outcome with more efficiency and safety.

Bilateral Ocular Ischaemic Syndrome-Rare Complication of Rhinocerebral Mucormycosis in an Omani Patient: Case report and literature review.

Ocular ischaemic syndrome (OIS) is a relatively uncommon condition. Simultaneous bilateral involvement is even less common and has been reported in only 22% of all cases of OIS. It has variable clinical presentations, of which visual loss and ocular pain are the most common. It is believed to occur when there is a 90% or greater carotid artery obstruction. This syndrome is often associated with a number of systemic diseases including diabetes mellitus, hypertension, coronary artery disease, and cerebrovascular disease. Only occasionally has it been described as a complication of rhinocerebral mucormycosis. We report an unusual case of bilateral OIS secondary to bilateral internal carotid artery thrombosis as a complication of invasive rhinocerebral mucormycosis. In addition, a review of clinical presentation, diagnostic work-up and treatment options for OIS is provided.

Outcome of rhegmatogenous retinal detachment repair: Experience of a tertiary center in Oman.

AIM: To study the outcome of repair of rhegmatogenous retinal detachment (RRD) in a tertiary center. MATERIALS AND METHODS: Review of electronic medical records within a period of 29 months of consecutive patients who underwent surgical repair for RRD in Sultan Qaboos University Hospital (SQUH). RESULTS: We included 33 consecutive patients (36 eyes). Males constituted 70% of them. The average age was 47 years. Seven eyes out of the 36 had macula-on RRD at presentation. The primary success rate with a single procedure was 86%. However, redetachment occurred in five eyes (14%). Visual acuity was either same as preoperative or better in 81% of the eyes. Giant retinal tear was found in three eyes (8%). The average follow-up period for all patients was 10.25 months (range: 3-25 months). CONCLUSION: Rhegmatogenous RD is not uncommon disorder. It occurs more frequently in males. However, it has a good prognosis if an intervention was performed in early stages.

Half-fluence photodynamic therapy to treat chronic central serous chorioretinopathy: A case series.

OBJECTIVE: To evaluate the efficacy and safety of half-fluence photodynamic therapy (PDT) in treating chronic central serous chorioretinopathy (CSC) in Omani population. MATERIALS AND METHODS: A Retrospective chart review of all patients with chronic CSC treated with half-fluence PDT from November 2009 to December 2010 was carried out. Recorded parameters included best-corrected visual acuity, findings of clinical examination, results of fluorescein angiography and optical coherence tomography at baseline and during follow-up visits after treatment. RESULTS: Six eyes (of five Omani patients) with chronic CSC, of at least 9 months duration, were treated with half-fluence PDT. All eyes showed a complete resolution of CSC within 1 month following treatment. Four eyes showed visual improvement and two had unchanged stable vision. No complications from the treatment were noticed during the follow-up visits. CONCLUSION: Half-fluence PDT to treat chronic CSC in Omani population is a promising treatment that results in both structural and functional improvement.